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Dementia
Dementia is a chronic, progressive decline in cognitive ability. It is a diagnosis that has significant morbidity and mortality associated with it for both the patient and the patient's family. It is vital to rule out dementia mimics including: delirium and depression before a diagnosis of dementia can be made. Prevalence is approximately 10% age >65. Delirium Definition 1. Disturbance in consciousness - change in focus/attention/ distractible 2. Disturbance in cognition - change in memory, disorientation, trouble with speech/language 3. Temporal fluctuation - develop over short period of time, fluctuates over hours 4. Evidence of underlying medical d/o Etiology I WATCH DEATH * I- Infections * W-withdrawal * A-Acute metabolic d/o (lytes, hepatic failure, renal failure) * T-Trauma (head trauma, post-operative) * C-CNS pathology (CVA, hemorrhage, tumour, seizure) * H-Hypoxia * D- Deficiencies of vitamins (B12, Folate, thiamine) * E-Endocrinopathies (thyroid, parathyroid, adrenal, glucose * A-Acute vascular (shock, HTN encephalopathy, vasculitis) * T-Toxins, substance use, MEDICATIONS * H- heavy metals (arsenic, lead, mercury) Investigations Consider the following based on history, physical * Physical: vitals, hydration status, r/o fecal impaction, urinary retention, infected ulcer * Blood work: CBC, lytes, Cr, extended lytes - Ca,P,Mg, albumin, TSH, B12, folate, LFTs, glucose, drug levels, tox screen, blood gas, septic w/u - CXR, urinalysis +/- blood cultures, CK, trop * Further w/u:ECG, head CT, Lumbar Puncture, EEG * ***REVIEW MEDICATION LIST*** Delirium vs Dementia PLEASE NOTE the below table is a generalization and there are exceptions to the rules. Depression See depression page* Screening: SIGECAPS: sleep disturbance, interest loss, guilt (regrets), energy decreased, concentration difficulties, psychomotor changes, suicidal ideation, low mood Poor sleep - look for 6 Ps (pain, PND/orthopnea, Pee - BPH, diuretic, partner, pharmaceuticals (diuretic, stimulants, caffeine, cholinesterase inhibitor, physical environment -temperature/noise) Decreased interest - depression patients operate below their abilities. Dementia - operative above their abilities and withdraw due to social embarrassment Dementia Cognitive symptoms 1. Amnesia: short term memory loss, repeating questions/stories, forgetting details of recent important events, trouble with names, increased use of compensatory strategies (e.g. lists) 2. Aphasia: word finding difficulty, decreased fluency, simplified speech, impaired comprehension, decreased reading/writing, mixing up languages 3. Apraxia: dressing apraxia, difficulty following physical examination, hitting nail with hammer, using appliances 4. Agnosia: difficulty recognizing objects/family/faces 5. Visuospatial: easily disorientated/lost in new environment, trouble driving in non-routine places 6. Calculation: financial difficulties 7. Executive functioning: sequence, organization, abstraction, planning. Trouble with ADLs and iADLs ADLs and iADLS ADLS: activities of daily living * DEATH: dressing, eating, ambulation, transfers, hygiene iADLS: instrumental activities of daily living * SHAFT: 'shopping, housekeeping/hobbies, accounting, food preperation, telephone/tool use/transportation (driving)/tablets (medications) '** IF lose 1ADL or 2+ iADLS need to R/A driving, finances, medication compliance** Definition of Dementia 1. Amnesia 2. Apraxia, aphasia, agnosia, executive dysfunction 3. Progressive 4. Impacts on function Meets criteria #1-4 Types of Dementia: *Vascular risk factors: HTN, DM, CAD, CVA, smoking, PVD *CJD - creutzfeldt-Jakob disease: rapid, progressive with balance and swallowing change 'Screening:' Mini-mental status examination: MMSE Montreal Cognitive Assessment MOCA EXIT-25 (frontal lobe dysfunction) Frontal Assessment Battery RUDAS Trails A & B 'Treatment' * Refer to alzheimers society * Discuss will, power of attorney, safety (driving, home) * Review medications and eliminate any unnecessary medications * Alzheimers disease ** Obtain ECG prior to treatment. Avoid AchEI if LBBB, AV blocks, Sick sinus syndrome, bradycardia< 50 ** Donepezil (aricept) ** Rivastigmine (exelon) ** Galantamine (reminyl) ** Memantine (Ebixa) * Vascular: modify vascular risk factors * Fronto temporal dementia: SSRI or trazodone. NO AchEI! * Lewy Body: ** rivastigmine (exelon) ** AVOID NEUROLEPTICS * Consider referral for rapid progression, young patients, frontotemporal, lewy body, parkinson's dementia 'Resources' Patient Handout: 10 Warning Signs of Dementia (Alzheimers Society)